Attention: All Providers

2007 Checkwrite
Schedule

Beginning February 2007, the cutoff day for electronic claims
submission will change from Friday to Thursday due to anticipated increased
processing time for the National Provider Identifier (NPI) implementation. It
is important that you make any required system changes to accommodate this
cutoff day. Following is the 2007 checkwrite schedule:

Attention:
All Providers

Effective with date
of service August 1, 2006, the N.C. Medicaid program covers CPT codes for the
intranasal and oral administration of vaccines/toxoids. Their code descriptors
are as follows:

90467- Immunization administration under 8 years of age (includes intranasal
or oral routes of administration) when the physician counsels the
patient/family; first administration (single or combination vaccine/toxoid) per
day. (For N.C. Medicaid, do not report in addition to 90465.)

90468- Each additional administration (single or combination vaccine/toxoid)
per day (list separately in addition to code for primary procedure). (For N.C.
Medicaid, use 90468 in conjunction with 90465.)

90473- Immunization administration by intranasal or oral route; one vaccine
(single or combination vaccine/toxoid). (For N.C. Medicaid, do not report in
addition to 90471.)

90474- Each additional vaccine (single or combination vaccine/toxoid). (List
separately in addition to code for primary procedure.) (For N.C. Medicaid, use
90474 in conjunction with 90471.)

The current codes
used for immunization administration and their descriptors are as follows:

90465- Immunization administration under 8 years of age (includes
percutaneous, intradermal, subcutaneous, or intramuscular injections) when the
physician counsels the patient/family; first injection (single or combination
vaccine/toxoid) per day. (For N.C. Medicaid, do not report 90465 in conjunction
with 90467.)

90466- Immunization administration under 8 years of age (includes
percutaneous, intradermal, subcutaneous, or intramuscular injections) when the
physician counsels the patient/family; each additional injection (single or
combination vaccine/toxoid) per day. (List separately in addition to code for
primary procedure.) (For N.C. Medicaid, use in conjunction with 90465 or
90467.)

The following
principles should guide the billing of the six codes described above:

1. Apply the appropriate code depending on the age of
the recipient and whether or not the physician has counseled the recipient and
family.

2. CPT codes 90465 and 90466 are in the same code
family, and 90471 and 90472 are in the same code family. A code from one
injectable code family cannot be used with a code from another injectable code
family.

3. CPT codes 90467 and 90468 are in one code family
and 90473 and 90474 are in another code family. A code from one intranasal/oral
code family cannot be used with a code from the other intranasal/oral code
family.

4. The physician counseling codes should not be used
as an “add-on” counseling code to the other administration codes.

6. When
billing 90465, 90466, 90467 or 90468, the physician, nurse practitioner,
or physician assistant must perform face-to-face
vaccinecounseling associated with the administration and should
document such. The physician, nurse practitioner, or physician assistant is
not required to administer the vaccine.

7. A “first” administration is defined as the first
vaccine administered to a recipient during a single patient encounter.

8. At the present time, there should not be an
occasion to bill a second intranasal/oral vaccine administration code.

9. When billing one or more injectable vaccines along
with one oral/intranasal vaccine, the code for thefirst injectable
vaccine is the primary code.

Billing Guideline Examples for Immunizations for Recipients Birth
through Age 20

Vaccine: InjectableProvider Type: Private Sector Providers

Service Type

With Physician Counseling

Without Physician Counseling

Health Check Screening with Immunization(s)

For one vaccine, bill 90465EP.

Report vaccine CPT code.

For two or more vaccines, bill 90465EP with 90466EP.
Report vaccine CPT codes.

Immunization diagnosis code(s) not required.

Immunization procedure code(s) are required.

For one vaccine bill 90471EP.

Report vaccine CPT code.

For two or more vaccines bill 90471EP and 90472EP.
Report vaccine CPT codes.

Immunization diagnosis code(s) not required.

Immunization procedure code(s) are required.

Immunization(s) Only

For one vaccine, bill 90465EP.

Report vaccine CPT code.

For two or more vaccines, bill 90465EP and 90466EP.
Report CPT vaccine codes.

One immunization diagnosis code is required.

Immunization procedure code(s) not required.

For one vaccine, bill 90471EP.

Report vaccine CPT code.

For two or more vaccines, bill 90471EP and 90472EP.
Report CPT vaccine codes.

One immunization diagnosis code is required.

Immunization procedure code(s) not required.

Office Visit with

Immunization(s)

For one vaccine, bill 90465EP.

Report vaccine CPT code.

For two or more vaccines, bill 90465EP and 90466EP.
Report CPT vaccine codes.

Immunization diagnosis code(s) not required.

Immunization procedure code(s) are required.

For one vaccine, bill 90471EP.

Report vaccine CPT code.

For two or more vaccines, bill 90471EP and 90472EP.
Report CPT codes.

Immunization diagnosis code(s) not required.

Immunization procedure code(s) are required.

Core Visit with Immunization(s)

N/A

N/A

Vaccine: InjectableProvider Type: FQHC/RHC

Service Type

With Physician Counseling

Without Physician Counseling

Health Check Screening with Immunization(s)

For one vaccine, bill 90465EP.

Report vaccine CPT code.

For two vaccines or more, bill 90465EP and 90466EP.
Report CPT vaccine codes.

Immunization diagnosis code(s) not required.

Immunization procedure code(s) are required.

For one vaccine, bill 90471EP.

Report vaccine CPT code.

For two vaccines or more, bill 90471EP and 90472EP.
Report CPT vaccine codes.

Immunization diagnosis code(s) not required.

Immunization procedure code(s) are required.

Immunization(s) Only

For one vaccine, bill 90465EP.

Report vaccine CPT code.

For two vaccines or more, bill 90465EP and 90466EP.
Report CPT vaccine codes.

One immunization diagnosis code is required.

Immunization procedure code(s) is not
required.

For one vaccine, bill 90471EP.

Report vaccine CPT code.

For two vaccines or more, bill 90465EP and 90466EP.
Report CPT vaccine codes.

One immunization diagnosis code is required.

Immunization procedure code(s) is not
required.

Office Visit with Immunization(s)

For one vaccine, bill 90465EP.

Report vaccine CPT code.

For two vaccines or more, bill 90465EP and 90466EP.
Report CPT vaccine codes.

Immunization diagnosis code(s) not required.

Immunization procedure code(s) are required.

For one vaccine, bill 90471EP.

Report vaccine CPT code.

For two vaccines or more, bill 90471EP and 90472EP.
Report CPT vaccine codes.

Bill 90471 administration code or E/M code. May bill
E/M code with modifier 25 appended in addition to 90471 if a separately
identifiable service was performed.

Bill vaccine CPT code.

Bill 90471 and 90472. May bill E/M code with
modifier 25 appended in addition to 90471 and 90472 if a separately
identifiable service was performed.

Bill CPT vaccine codes.

Vaccine: InjectableProvider Type: FQHCs/RHCs

Service Type

Number of Vaccines

One

Two or More

Immunization(s) Only

Bill under the C suffix code.

Bill 90471 administration code

Report the vaccine code if vaccine was provided at
no charge from the State of North Carolina.

OR

Bill the vaccine CPT code if vaccine was purchased.

Report diagnosis codes as appropriate.

Bill 90471 and 90472 administration codes.

Report the CPT vaccine codes if vaccines were
provided at no charge from the State of North Carolina.

OR

Bill the CPT vaccine codes if the vaccines were
purchased.

Report diagnosis codes as appropriate.

Core Visit with Immunization(s)

Immunization administration fees cannot be billed
with core visits.

Immunization administration fees cannot be billed
with core visits.

Vaccine: InjectableProvider Type: Local Health Departments

Service Type

Number of Vaccines

One

Two or More

Immunization(s) Only

Bill 90471 administration code.

Bill vaccine CPT code.

Report diagnosis codes as appropriate.

Bill 90471 and 90472.

Bill CPT vaccine codes.

Report diagnosis codes as appropriate.

Office Visit with Immunization(s)

Bill 90471 administration code or E/M code. May bill
E/M code with modifier 25 appended in addition to the administration code if
a separately identifiable service was performed.

Bill vaccine CPT code.

Bill 90471 and 90472. May bill E/M code with
modifier 25 appended in addition to 90471 and 90472 if a separately
identifiable service was performed.

Bill CPT vaccine codes.

Currently, providers cannot bill for an intranasal or oral vaccine
alone or in addition to an injectable vaccine for recipients 21 years of age
and older.

EDS,
1-800-688-6696 or 919-851-8888

Attention: All Providers

Influenza Vaccine and Reimbursement Guidelines for
2006-2007

The North Carolina Medicaid
program reimburses for vaccines in accordance with guidelines from the Centers
for Disease Control and Prevention (CDC) and the Advisory Committee on
Immunization Practices (ACIP). Information pertinent to influenza disease, vaccine,
and recommendations regarding who should receive the vaccine for the 2006–2007
flu season can be found at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5510a1.htm?s_cid=rr5510a1_e

Per ACIP, annual influenza vaccination is recommended for
the following groups.

1. Persons with increased risk for complications from influenza:

children aged 6–23 months

children and adolescents (aged 6 months through 18 years) who are
receiving long-term aspirin therapy

women who will be pregnant during the influenza season

adults and children who have chronic disorders of the pulmonary
or cardiovascular systems, including asthma (hypertension is not considered a
high-risk condition)

adults and children who have required regular medical follow-up
or hospitalization during the preceding year because of chronic metabolic
diseases (including diabetes mellitus), renal dysfunction, hemoglobinopathies,
or immunodeficiency (including immunodeficiency caused by medications or by
human immunodeficiency virus [HIV])

adults and children who have any condition (e.g., cognitive
dysfunction, spinal cord injuries, seizure disorders, or other neuromuscular
disorders) that can compromise respiratory function or the handling of
respiratory secretions or that can increase the risk for aspiration

residents of nursing homes and other chronic-care facilities that
house persons of any age who have chronic medical conditions

3. Persons who live with or care for persons at
high risk for influenza-related complications:

healthy household contacts and caregivers of children aged
0–59 months and persons at high risk for severe complications from
influenza

health-care workers

4. Healthy young children aged 6–59 months

The North Carolina Immunization Branch distributes childhood
vaccines to local health departments, hospitals, and private providers under
guidelines of the North Carolina Universal Distribution Program/Vaccine for
Children (UCVDP/VFC).

UCVDP/VFC influenza vaccine is available at no charge to
providers for children who meet one of the following criteria:

all healthy children 6 months through 59 months of age;

all high-risk children 6 months through 18 years of
age, as identified in the ACIP recommendations

any child (6 months through 18 years of age) who is
a household contact of

a. any child age 0 through 59 months of age or

b.
any high-risk child or adult

Billing Reminders:

Medicaid does not cover influenza vaccine that is supplied
through UCVDP/VFC for recipients through 18 years of age.

Medicaid will reimburse for either the injectable or the
intranasal (FluMist) influenza vaccine for those recipients 19 through 20
years of age who are vaccinated in accordance with the ACIP
recommendations.

Medicaid does not reimburse for FluMist for recipients aged
21 years or older.

Medicaid will reimburse for the administration of FluMist
vaccine by either CPT code 90467, 90468, 90473 or 90474 with the EP
modifier appended.

Private providers may bill for administration fees of the
injectable vaccines when physician counseling is NOT performed using CPT
code 90471 or 90471 and 90472 with the EP modifier for recipients under 19
years of age. If physician counseling IS performed for children under the
age of 8 years, bill using CPT code 90465 or 90465 and 90466 with the EP
modifier. Local health departments may bill CPT code 90471 (non-physician
counseling) or 90465 (physician counseling for recipients under 8 years of
age), as appropriate, with the EP modifier for any visit other than a
Health Check screening. Rural health clinics and federally qualified
health centers, using the C suffix, may bill 90471 or 90465 if the
immunization administration is during a Health Check visit.

For recipients 19 and 20 years of age in the high-risk
categories, private providers may bill Medicaid for injectable influenza
vaccine using CPT procedure code 90656 or 90658 and the administration
CPT code 90471 or 90471 and 90472 with the EP modifier. Local health
departments can bill for the influenza vaccine for 19 and 20 year olds
using CPT procedure code 90656 or 90658 and the administration CPT code
90471.

Private providers and local health departments may bill
Medicaid for injectable influenza vaccine for high-risk adults 21 or
more years of age using CPT code 90656 or 90658 and the administration
CPT code 90471
or 90471 and 90472.

The following tables indicate the vaccine codes that can
either be reported or billed for an influenza vaccine, depending on the age of
the recipient. The tables also indicate the administration codes that can be
billed, depending on the age of the recipient.

NOTE: The information in the following tables IS NOT
detailed billing guidance. Specific information on billing ALL immunization
administration codes can be found in this bulletin (“CPT Codes 90467, 90468,
90473 and 90474—Coverage of Immunization Administration Codes for
Oral/Intranasal Vaccines,”).

Table 1 Influenza
Billing Codes for Recipients Less Than 19 Years of Age

Vaccine CPT Code to Report

CPT Code Description

90655

Influenza virus
vaccine, split virus, preservative free, for children

6-35 months of
age, for intramuscular use

90656

Influenza virus vaccine,
split virus, preservative free, for use in individuals 3 years and above, for
intramuscular use

90657

Influenza virus vaccine,
split virus, for children 6-35 months of age, for intramuscular use

90658

Influenza virus vaccine,
split virus, for use in individuals 3 years of age and above, for
intramuscular use

90660

Influenza virus vaccine,
live, for intranasal use (FluMist)

Administration CPT Code(s) to Bill

CPT Code Description

90465EP

Immunization administration
under 8 years of age (includes percutaneous, intradermal, subcutaneous
or intramuscular injections); when the physician counsels patient/family;
first
injection (single or combination vaccine/toxoid), per day

90466EP

Each additional injection
(single or combination vaccine/toxoid), per day (list separately in addition
to code for primary procedure)

90467EP

Immunization administration
under age 8 years (includes intranasal or oral routes of administration) when
the physician counsels the patient/family; first administration (single or
combination vaccine/toxoid), per day

90468EP

Each additional
administration (single or combination vaccine/toxoid), per day (List
separately in addition to code for primary procedure)

NOTE: billing CPT code
90468 for a second administration of an intranasal/oral vaccine when
physician counseling was performed is not applicable at this time.

For a recipient 21 years of age
or older receiving an influenza vaccine, an evaluation and management (E/M)
code
cannot be reimbursed to any provider on the same day that injection
administration fee codes (90471 or 90471 and 90472)
are reimbursed, unless the provider bills an E/M code for a separately identifiable
service by appending
modifier 25 to the E/M code.

EDS, 1-800-688-6696 or 919-688-6696

Attention: All Providers

Medicare Part D Prescription Drug Changes Beginning Jan. 1, 2007

Medicare and Social Security
are making decisions about whether some people who qualify for extra prescription
drug help, low income subsidy (LIS) or dual status in 2006, will continue
to
qualify in 2007. Therefore, beginning Jan.1, 2007, providers should
verify if an individual continues to qualify for the low- income subsidy
(LIS), or dual status, which means these individuals would have co-pays as
low as $0
and as high as $5.35. Providers should also remember to verify the
prescription drug plan (PDP), as some individual plans may change with an
effective date of Jan 01, 2007.

Individuals affected by these
changes will receive information and notices from Medicare or Social Security. The
individuals that receive notices stating that they will not qualify for the
extra prescription drug help in 2007 are encouraged to complete another
application, which will be enclosed with their notice.

Individuals that will
automatically continue to qualify for the extra help in 2007 will also receive
notices. These notices will state that they continue to qualify for the extra
prescription drug help for 2007, and they do not need to take any action, as
they will automatically continue to be enrolled for the extra prescription drug
assistance. Also, these individuals who continue to automatically qualify for
the extra prescription drug help in 2007 may be subject to co-pay increases or decreases.
The co-payment level change will depend upon changes to their living
arrangement, income level, resources, and household size.

EDS, 1-800-688-6696 or 919-851-8888

Attention: All Providers

New Claim Form Instructions Special Bulletin

The CMS 1500 (12/90), the UB92 and the American Dental
Association (ADA) 2002 paper forms have been revised and will be replaced
with the new CMS 1500 (08/05), the UB-04 and ADA 2006 claim forms, respectively.

Providers may access the December 2006
Special Bulletin, New Claim Form Instructions. Providers
should contact EDS with any billing questions.

EDS, 1-800-688-6696 or 919-851-8888

Attention: All Providers

NDCs On Outpatient Physician-Administered Drug
Claims

The Deficit Reduction Act of 2005
(DRA) includes provisions regarding State collection and submission of data for
the purpose of collecting Medicaid drug rebates from manufacturers for all
outpatient drug claims. In order to do this, North Carolina Medicaid will
require that outpatient drug claims include both the National Drug Code (NDC)
and the NDC units in addition to the HCPCS code and units. This change will be
implemented sometime mid-2007 for providers who bill for drugs on the CMS-1500
claim form and for dialysis providers who bill drugs on the UB-92 claim form.
The NDC numbers and NDC units will be required on the 837P and 837I transaction
sets. Please look for future bulletin articles regarding this change.

EDS, 1-800-688-6696 or 919-851-8888

Attention: All Providers

National Provider Identifier (NPI) Seminars

National Provider Identifier (NPI) seminars are being held during the month
of January 2007. Seminars are intended for providers that would like more
detailed information on how NC Medicaid will be implementing NPI.

The seminars are scheduled at the locations listed below. Pre-registration
is required. Due to limited seating, registration is limited to two staff members
per office. Unregistered providers are welcome to attend if space is available.

Providers may register for the NPI seminars by completing and submitting
the registration form or by registering
online.
If
you are planning on attending the Raleigh location that has 2 sessions, please
indicate the session you plan to attend on the registration form. Morning
sessions of the seminars will begin at 9:30 a.m. and end at 11:30 a.m.

Providers are encouraged to arrive by 9:15 a.m. to complete registration.
Afternoon sessions will begin at 1:30 p.m. and end at 3:30 p.m. Providers
are encouraged
to arrive by 1:15 to complete registration.

“Get It! Share It! Use It! Now! Getting one is free - Not having one can be costly!”

Attention: All Providers

Payment Error Rate Measurement in North Carolina

In compliance with the Improper Payments Information Act
of 2002, the Centers for Medicare and Medicaid Services (CMS) implemented
a
national Payment Error Rate Measurement (PERM)program to measure
improper payments in the Medicaid program and the State Children’s Health
Insurance Program (SCHIP). This is to inform you that North Carolina has
been selected as one of 17 states required to participate in PERM reviews
for Federal
fiscal year 2007 (Oct.1, 2006 – Sept.30, 2007).

CMS is using three national contractors to measure improper
payments. One of the contractors, Livanta LLC (Livanta), will be communicating
directly with providers and requesting medical record documentation associated
with the sampled claims (approximately 800-1200 claims for North Carolina).
Providers will be required to furnish the records requested by Livanta, within
a timeframe indicated by Livanta.

Providers are reminded of the requirement in Section
1902(a)(27) of the Social Security Act and Federal Regulation 42 CFR Part
431.107 to retain any records necessary to disclose the extent of services
provided to individuals and, upon request, furnish information regarding any
payments claimed by the provider for rendering services.

Provider cooperation to furnish requested records is
critical in this CMS project. No response to requests and/or insufficient
documentation will be considered a payment error. This can result in a payback
by the provider and a monetary penalty for North Carolina Medicaid.

Program Integrity DMA, 919-647-8000

Attention: All Providers

Required
Fields on New Provider Enrollment Applications and Provider Change Form

Effective January 1, 2007, to facilitate NPI implementation, the Division
of Medical Assistance (DMA) will no longer accept enrollment applications
or change forms without the following information:

Attention: All Providers

Effective with date of service Aug.1, 2006, the N.C.
Medicaid program recognizes rotavirus vaccine as a covered vaccine in the
Universal Childhood Vaccine Distribution Program (UCVDP)/Vaccine for Children
(VFC) program.
The UCVDP/VFC program provides all vaccines recommended by the Advisory
Committee on Immunization Practices (ACIP) of the Centers for Disease Control
and Prevention (CDC). Currently, there is one rotavirus vaccine product,
RotaTeq, manufactured by Merck and Company.

Rotavirus vaccine should be
administered in three doses. The first dose should be administered between 6 and
12 weeks of age, with two subsequent doses administered at 4- to 10-week
intervals and all three doses administered by 32 weeks of age.

Medicaid does not reimburse for the actual vaccine for
children between 6 and 32 weeks of age because state-supplied vaccine is
available to all providers enrolled in the UCVDP/VFC program. Medicaid will
reimburse for a vaccine administration fee, if applicable. When state-supplied
rotavirus vaccine is administered, the ICD-9-CM diagnosis code V04.89 should be
indicated on the claim when appropriate.

Billing Guidelines

Report rotavirus vaccine with CPT procedure code 90680.

Use ICD-9-CM diagnosis code V04.89 when reporting
rotavirus.

Effective with date of service Aug.1, 2006:

Report CPT procedure code 90680 with no modifier at a
charge of $0.00 for vaccine that was state-supplied and administered to a
Medicaid recipient 6 to 32 weeks of age.

Bill CPT code 90467 with the EP modifier when provider
counseling is provided for children under 8 years of age.

Refer to “CPT Codes 90467, 90468, 90473 and 90474—Coverage
of Immunization Administration Codes for Oral/Intranasal Vaccines,”p.4,
for how to bill using immunization administration codes.

Providers who have had claims denied for dates of service
on or after Aug.1, 2006, may re-file those claims.

EDS, 1-800-688-6696 or 919-851-8888

Attention: All Providers

Submitting Both National Provider Identifier (NPI) and Provider Number
on Claims

N.C. Medicaid would like to
encourage providers to begin submitting both the NPI and the Medicaid provider
number on electronic claims no later than Jan.1, 2007. If your software
is not updated to submit the NPI number, please contact your clearinghouse
or software
vendor as soon as possible to obtain the appropriate updates. Please ensure
that you keep the capability to submit the Medicaid provider number along
with the NPI. N.C. Medicaid will continue to process claims using the Medicaid
provider number until NPI is implemented in May 2007.

The NCECS Webtool already
contains a field for submitting the NPI, so providers can begin to populate
that field. For providers who bill on paper, the new paper claim forms will
be available in 2007. We plan to begin testing changes to the MMIS in Jan.2007
and at that time we will need both the NPI and Medicaid provider numbers.

“Get It! Share It! Use It! Now! Getting one is free - Not
having one can be costly!”

EDS, 1-800-688-6696 or 919-851-8888

Attention: All Providers

Termination of Community Alternatives Program for Persons with AIDS

Effective with date of service Dec.31, 2006, N.C.
Medicaid will terminate the Community Alternatives Program for Persons with
AIDS (CAP/AIDS) Waiver Program. A transition plan has been developed to
refer the current CAP/AIDS recipients to other waiver programs, where they
will be
reassessed for participation.

Current providers of CAP/AIDS Waiver services must verify
their recipients’ participation in either CAP/DA (Disabled Adults) or CAP/C
(Children) before providing services on or after January 1, 2007. The January
2007 Medicaid ID cards for the recipients who choose and are eligible to
continue CAP participation will have new CAP indicator codes consistent with
the waiver
programs they select (CS or CI for CAP/DA; HC, SC or IC for CAP/C).

Waiver Services Offered

Additionally, case managers are responsible for issuing new
service authorizations to providers of waiver services. These are required to
authorize services before billing may occur. The waiver services for
CAP/DA include:

Adults - All future referrals for recipients aged
18 and above who have an AIDS diagnosis, are appropriate for nursing home
level
of care, and have a need for services formerly covered under the CAP/AIDS
program
should be made by contacting the CAP/DA Lead Agency for the county where
the recipient resides.

Children - Recipients
aged 18 and under who meet the criteria below should be referred to CAP/C
by contacting the local case
management agency or the Home Care Initiatives Unit at DMA, 919-855-4380.

Requirements for Children to
Transition from CAP/AIDS to CAP/C

One of These…

AND…

AND…

Be an individual up to age 18 who is diagnosed with
AIDS, OR

Be a child up to 2 years of age who is seropositive,
OR

Be a child 2 through 12 years of age who is HIV
seropositive and who has at least two conditions resulting from the HIV
infection. These are conditions that place the child in clinical category
A, B or C as defined by the Centers for Disease Control and Prevention
(CDC).

Be appropriate for nursing home level of care and
meet the criteria for risk of institutionalization

Have needs for Medicaid coverage of in-home nursing
or nurse-aide services. These services must include actual interventions
that are medically based, continuous in nature and not solely appropriate
to the child’s age.

Attention: All Providers

Updated Effective Dates for
Revised Billing Forms

This bulletin article is revised from the November 2006
general bulletin article.

The National Uniform Claim Committee (NUCC), the National
Uniform Billing Committee (NUBC) and the American Dental Association (ADA) have
issued revised professional, institutional and dental paper claim
formats.

The revised CMS 1500 (08/05) professional claim form will be
accepted by Medicaid as of Jan.1, 2007. In keeping with the
NUCC advisory, NC Medicaid will require that any paper CMS 1500 claims received
by EDS as of April 1, 2007 be filed using the new claim form. To
accommodate a transition period for providers, the Division of Medical
Assistance will allow providers the option of submitting either the current
CMS 1500 (12/90) form or the new CMS 1500 (08/05) form from Jan.1,2007
through
March 31, 2007 for Medicaid claims as well as provider-submitted Medicare
crossover claims. During this transition period, EDS will process
using either claim format; however, claims received on or after April 1, 2007
must be filed on the CMS 1500 (08/05).

The new UB04 claim form released by the NUBC for
institutional providers to replace the current UB92 claim form will be accepted
by North Carolina Medicaid beginning March 1, 2007. As with the CMS 1500
(08/05), the Division of Medical Assistance will allow a transition period for
providers to submit either the UB92 or the UB04 until April 30, 2007. Any paper
claims received on or after May 1, 2007 must be filed on the UB04 format.

The revised ADA 2006 claim form released by the ADA for
dental providers to replace the current ADA 2002 claim form will be accepted
by North Carolina Medicaid beginning March 1, 2007. The Division of Medical
Assistance will allow a transition period from March 1, 2007 through April
30,
2007 for providers to submit either the ADA 2002 or the ADA 2007 claim
forms. Any paper claims received on or after May 1, 2007 must be filed on
the ADA 2006 format.

EDS, 1-800-688-6696 or 919-851-8888

Attention: All Providers

Updated National Provider Identifier (NPI) Collection Forms

The Division of Medical
Assistance (DMA) is currently collecting National Provider Identifier (NPI)
numbers from Medicaid providers. Healthcare providers are required to complete
one NPI collection form for each Medicaid provider number to ensure that
North Carolina Medicaid captures the NPIs which will be used for claims processing. There
are now two different collection forms on the DMA Website: one for individual
provider numbers and one for group provider numbers. Providers
who have obtained an organizational or group NPI must complete an NPI collection
form for the group provider number. In addition, an individual NPI collection
form must be completed for each individual provider number within the group.

The required fields for
completing the NPI collection form are: Medicaid Provider Number, NPI,
Physical and Billing address including Zip +4 and taxonomy code(s). If more
than three taxonomy codes need to be linked to one NPI number, an additional
taxonomy page has been provided on the Web site. Providers can link up to
15 taxonomies to one NPI. Also, providers need to include a copy of the
notification letter from the National Plan and Provider Enumeration System
(NPPES). The address information provided will overlay the information
currently in the system. Any other change request will require a separate
change request form

The collection forms are located
on the following Website: NPI.
Forms must be typed and returned no later than March 15, 2007. The form
can be returned by the mail, fax or email addresses listed on the form. Providers
will receive a confirmation notice once the NPIs have been added.

“Get It! Share It! Use It! Now! Getting one is free -
Not having one can be costly!”

EDS, 1-800-688-6696 or 919-851-8888

Attention: CAP/DA Lead
Agencies and AQUIP Users

The fourth quarterly Automated Quality and Utilization
Improvement Program (AQUIP) training seminar for new AQUIP users in CAP/DA
lead agencies is scheduled for Dec.12, 2006, at the Park Inn in Hickory.

Attendance at this meeting is of the utmost importance for
new AQUIP users. CAP/DA lead agency contacts have been informed via e-mail of
any identified new AQUIP users in their counties who should attend this
session. Any current AQUIP users who would like to attend the session may do
so if space permits.

The AQUIP seminar is scheduled to begin at 9:00 a.m. and
end at 4:00 p.m. The session will begin with discussion of Resource Utilization
Group (RUGs) information. The seminar will then turn the focus toward how
to maneuver a new CAP/DA client from the waiting list through the termination
process while accurately completing the Client Information Sheet, Data Set
Assessment and Plan of Care. System overview will be addressed in the
afternoon.

Pre-registration is required; due to holiday scheduling
constraints, you will need to start registering as soon as possible on Dec.
1, 2006. Contact your CAP/DA lead agency to verify if your name is
on the required attendance list. You may register for the seminar online
by going to https://www2.mrnc.org/aquip and clicking
on Registrations. You will receive a computer-generated confirmation number,
which you should bring to the seminar. Check-in will be from 8:30 until
9:00 a.m. on the day of the seminar; lunch will be on your own.

Park Inn Hickory - Hickory

Traveling east or west on Interstate 40, take exit 123B to U.S. 321-Business/U.S. 70, exit 44. Turn right off the exit. The hotel and Gateway
conference center are on the right.

Prior
Authorization for Outpatient Specialized Therapies—Implementation Date for
Electronic Submission and New Forms

Beginning Feb.5,
2007, outpatient specialized therapy providers will have the option to
electronically
submit prior authorization (PA) requests. For providers who continue to
submit requests via fax or mail, the new PA form will also begin on Feb.5. Refer
to the July and October 2006 general Medicaid bulletins (pp. 9 and 11,
respectively) for background information about this procedure change.

On Dec.15, 2006,
details and instructions about electronic submission and the new form will
be available at https://www2.mrnc.org/priorauth/. All
site visitors will have access to the following information:

required documentation for
electronic and fax/mail submission and how the new process differs from the
current one

description of Web site features
for providers who plan to use electronic submission

instructions to register provider
number and obtain log-in information

downloadable new PA form and
instructions

fAQs about the PA process

Once
a provider registers and obtains log-in information, the following information
will also be available:

All
provider training and education about electronic submission and the new PA form
will be performed through the Web site. After viewing the information, submit
any questions/comments about the new PA process to CCME at priorauth@thecarolinascenter.org.

Ancillary
ServicesDMA, 919-855-4310

Attention: CMS
Billers

CMS-1500 (08/05)
Claim Form Information

CMS-1500 (08/05) – Medicaid will begin accepting the new
claim form on Jan.1, 2007. Please review the NUCC website at www.nucc.org for information and view the
instruction manual.

EDS, 1-800-688-6696 or 919-851-8888

Attention: Hospice Providers

Billing for
Hospice Nursing Facility Room and Board Charges

Claims for reimbursement of hospice nursing facility room
and board submitted on or after Dec.1, 2006, must list the provider
number of the facility where the recipient is in residence. This requirement
applies to revenue codes 658, intermediate care, and 659, skilled care. Enter
the provider number in form locator 82 on the UB-92 claim form or in the
“Attending
Physician ID (UPIN)” field when billing electronically. Both of the revenue
codes will reimburse 95% of the nursing facility rate.

Hospice claims submitted for revenue code 658 or 659 without
the nursing facility’s provider number in the appropriate block will be denied.

EDS, 1-800-688-6696 or 919-851-8888

Attention: Nursing Facility Providers

Activities of
Daily Living (ADL) Clarification for Minimum Data Set (MDS) Validation Review

It is essential that ADL keys used by nursing facilities to
code section G of the MDS are equivalent to the intent and definition of the
MDS ADL key and Resident Assessment Instrument (RAI) Manual. Late loss ADL MDS
values (including bed mobility, transfers, an eating component, and toilet use)
are reviewed for all assessments selected for the MDS Validation review.
Therefore, correct ADL definitions, supported by documentation, are crucial to
a successful review. Some of the generic keys used in nursing facilities are
missing key words found in the MDS key, resulting in unsupported reviews
because they are inconsistent with the definitions in the RAI manual.

Some nursing facilities choose to use one set of ADL
definitions on the Certified Nursing Assistant (CNA) documentation tool and a
different set of definitions for the licensed nurse documentation. In this
case, the facility must specify which set of ADL definitions will be used for
the review.

Nursing facilities whose ADL definitions deviate from the
MDS ADL key should use words that maintain the intent of the definitions
like the words in bold below.

Code

Self
Performance

Definition

0

Independent

No help or oversight

1

Supervision

Oversight, encouragement, cuing

2

Limited assistance

Resident highly involved in activity; received physical
help in guided maneuvering of limbs or other non–weight-bearing assistance

3

Extensive assistance

Resident performed part of activity, help of the
following provided:

weight-bearing support

full staff performance

4

Total dependence

Full staff performance

8

Activity did not occur

If the ADL key intent is not clear, the MDS Validation reviewers
cannot support the ADL documentation.

Other ADL MDS Validation Review Requirements:

Providers with no ADL key associated with the ADL values
will be considered unsupported.

Providers with two different ADL supporting documentation
tools per assessment (one the CNA completes and one the licensed nurse completes)
will be asked to designate the one to be used for the MDS Validation
review. The designated tool must be maintained in the medical record as a
legal document.

ADL keys with words for self-performance such as limited,
extensive assist, etc., without the full definitions will be considered
unsupported for the MDS Validation review.

All MDS ADL codes must be represented on the ADL
supporting documentation tool. For example, for self performance, the ADL
supporting documentation tool must contain the codes for independent,
supervision, limited assistance, extensive assistance, total dependence,
and activity did not occur. ADL tools that lack codes for all the
possible MDS coding options will not be accepted as supporting
documentation.

The ADL supporting documentation tool must contain the
appropriate keys for both self-performance and support provided.

The above criteria will be enforced beginning with
assessments dated (in box A3a) on or after Jan.1, 2007.

Contacts for questions related to
the MDS or MDS Validation Program are as follows:

Myers and StaufferPatty Padula or Cindy Smith1-317-846-9521

North Carolina MDS Help LineCindy DePorter, State RAI/MDS Coordinator919-715-1872

Attention: Nursing Facility Providers

Nursing
Facility Quality Improvement Initiatives

North Carolina Medicaid case mix reimbursement to nursing
facilities began in October 2003. As a condition of receiving case mix
reimbursement, nursing facilities are required to participate in quality
improvement initiatives.

Points to consider when adopting quality initiatives are
listed below:

1. A
quality improvement initiative is a facility-wide program that has a measurable
impact on the quality of care the resident receives or the quality of life the
resident enjoys.

2. The
impact of the initiative should be supported by current research or statistical
data.

3. A
quality improvement initiative could potentially span years. The initiative
should be evaluated and updated by the facility for effectiveness at least
annually.

4. Examples
of quality initiatives that a facility might adopt include programs designed to
retain and stabilize the direct-care workforce, incentive programs for
direct-care workers, long-term-care staff mentoring, educational programs for
staff, enhanced services for residents, and adoption of Best Practices
Guidelines or pieces of the facility’s existing quality assurance program.

5. The
facility must provide evidence that a program is in place. Evidence may
include written documentation, facility staff interviews (in writing, by
telephone, or in person), or an on-site review of program.

DMA supports the N.C. New Organizational Vision Award (NC
NOVA) quality initiative currently piloted in 30 different North Carolina
facilities and agencies. For more information about NOVA, go to the NOVA Website at http://www.ncnova.org.

Attention: Optical Service
Providers

Expediting
Medically Necessary Early Eye Exams and Visual Aids

Occasionally, an urgent situation may arise in which an
early eye exam or visual aid is medically necessary and requires expedition.

When this occurs, the provider should contact the Visual
Services Specialist at (919) 855-4310. If deemed medically necessary by the
Visual Services Specialist, the services will be expedited. Since each request
is unique, the Visual Services Specialist will provide specific processing
instructions for each approved, expedited request.

Continue to submit routine and non-urgent early eye exam and
visual aid prior approval requests to EDS on the following forms:

Eye exam—Request for Prior Approval North Carolina Medicaid
Program (372-118)

Visual aid—Request for Prior Approval for Visual Aids Form
(372-017 or 372-017A)

EDS, 1-800-688-6696 or 919-851-8888

Attention: Optical
Service Providers

Update
of ICD-9-CM Diagnosis Codes for Visual Field Exams (92081, 92082 and 92083)

According to the ICD-9-CM 2006 Professional Coding Manual
(6th edition), the following ICD-9-CM diagnosis codes for billing visual field
testing now require 4th and possibly 5th digits.

250.00

250.01

250.02

250.03

250.50

250.51

250.52

250.53

343.0

360.00

360.40

361.00

362.30

362.40

362.50

362.60

362.70

363.20

364.10

365.00

365.60

369.00

369.20

370.00

377.00

377.10

377.30

379.50

710.00

743.20

950.0

This list is not an all-inclusive listing of diagnosis codes
covered for visual field exams; it includes only the diagnosis codes that were
updated. Please refer to the Optical Services Manual located on the DMA Optical and Visual Services web page for further information on optical services.

Bevacizumab
(Avastin, J9035)—Update to Billing Guidelines

The N.C. Medicaid program covers bevacizumab (Avastin) for
use in the Physician’s Drug Program for the diagnosis of malignant neoplasm of
the colon, rectum, rectosigmoid junction, and anus when used in combination
with intravenous 5-fluorouracil–based chemotherapy. The Food and Drug

Administration also approved Avastin for the diagnosis of
unresectable, locally advanced, recurrent or metastatic non-squamous, non–small
cell lung carcinoma in combination with carboplatin and paclitaxel in October
2006.

In accordance with the new FDA-approved diagnosis for
Avastin, the following ICD-9-CM diagnosis codes are required when
billing for Avastin:

Effective with date of service March 1, 2006, the N.C.
Medicaid program covers ibandronate sodium (Boniva) injection for use in the Physician’s
Drug Program when billed with HCPCS procedure code J3490 (unclassified drug
code). Boniva injection is a nitrogen-containing bisphosphonate that inhibits
osteoclast-mediated bone resorption. It is indicated for the treatment of
osteoporosis in postmenopausal women. The injectable form of Boniva is intended
for intravenous administration only. According to the manufacturer’s
guidelines, Boniva should not be administered more often than every three
months. It is available in a 3-mg/3-mL single-use, prefilled syringe.

For Medicaid Billing:

Bill one of the following ICD-9-CM diagnosis codes for
Boniva:

733.01 (senile osteoporosis) OR

733.09 (drug-induced osteoporosis) with the E code to
identify the drug

Bill Boniva with HCPCS code J3490 (unclassified drug
code).

Submit an original invoice, or copy of the original
invoice, with the CMS-1500 claim form. An invoice must be submitted
with each claim. The paper invoice must include the recipient’s
name and Medicaid identification number, the name of the medication,
the dosage
given, the National Drug Code (NDC) number from the vial(s) used the
number of vials used, and the cost per dose.

Indicate the unit given in block 24G on the CMS-1500 claim
form.

Bill the usual and customary charge.

For Medicaid billing, one unit of coverage is the 3-mg/3-mL
syringe. The maximum reimbursement rate is $406.57 per unit. Claims denied for
dates of service on or after March 1, 2006, may be resubmitted.

Behavioral
Pharmacy Management Project

Division of Medical Assistance (DMA) is engaged in an
ongoing project to provide information to prescribers about behavioral
medication usage of N.C. Medicaid recipients. The informational product,
Behavioral Pharmacy Management (BPM), was developed by Comprehensive
Neuroscience, Inc. (CNS), an independent company. BPM analyzes pharmacy claims
for certain quality indicators that suggest a possible variance from generally
accepted evidence-based or consensus-based prescribing guidelines and thus may
either represent high risk to patients or pose problems for continuity and
coordination of care.

Once a month, prescribers are mailed information about any
of their patients whose pharmacy claims triggered such an alert. Feedback is
encouraged; a feedback form and addresses for Web-based or mailed responses are
included in the packet.

If any information in the packet is incorrect (for example,
not my patient, did not write script), please respond by faxing the prescriber
feedback form to 919-674-2538.

DMA, 919-855-4300

NCLeads Update

Information related to the implementation of the new Medicaid Management Information System,NCLeads, can be found online. Please refer to the NCLeads website for information, updates, and contact information related to the NCLeads system.

Provider Relations
Office of MMIS Services
919-647-8315

Proposed Clinical Coverage Policies

In accordance with Session Law 2005-276, proposed new or amended Medicaid clinical coverage policies are available for review and comment on DMA's website. To submit a comment related to a policy, refer to the instructions on the website. Providers without Internet access can submit written comments to the address listed below.

The initial comment period for each proposed policy is 45 days. An additional 15-day comment period will follow if a proposed policy is revised as a result of the initial comment period.

2007 Checkwrite Schedule

Month

Electronic
Cut-Off Date

Checkwrite
Date

December

12/01/06

12/05/06

12/08/06

12/12/06

12/15/06

12/21/06

January

01/05/07

01/09/07

01/12/07

01/17/07

01/19/07

01/25/07

February

02/02/07

02/06/07

02/08/07

02/13/07

02/15/07

02/20/07

02/22/07

02/28/07

Electronic claims must be
transmitted and completed by 5:00 p.m. on the cut-off date to be included in
the next checkwrite. Any claims transmitted after 5:00 p.m. will be processed on the second checkwrite following the transmission date.